1. Airway and ventilatory Management33
EMS Professions
Temple College
Dr. Sarwar Arif

2. Respiration
is the process of exchanging gases between the atmosphere and body cells.

3. Stages of Respiration
Ventilation: Movement of air into and out of lungs
External respiration: Gas exchange between air in lungs and blood
Transport of oxygen and carbon dioxide in the blood
Internal respiration: Gas exchange between the blood and tissues

4. The mechanics of breathing

5. Anatomy of the Upper Airway
Pediatric vs Adult Upper Airway
Larger tongue in comparison to size of mouth
Floppy epiglottis
Delicate teeth and gums
Larynx is more superior
Funnel shaped larynx due to undeveloped cricoid cartilage
Narrowest point at cricoid ring before 10 yoa

6. Opening the Airway Tongue is most common cause of airway obstruction
Use the head tilt–chin lift to lift tongue from back of throat and open airway
In a trauma patient, use jaw thrust

7. Chin lift

8. Chin lift
Fingers of one hand are placed under the mandible, which is gently lifted upward to bring the chin anterior.
The thumb of the same hand lightly depresses the lower lip to open the mouth.
Not hyperextend the neck.

9. Jaw trust

10. Jaw thrust
Grasping the angles of lower jaw ,one hand on each side,& displacing the mandible forward.

11. Airway & Ventilation Methods: ALS
Patient Positioning for Intubation
Goal
Align the 3 planes of view, so that
The vocal cords are most visible
T - trachea
P - Pharynx
O - Oropharynx
From AHA PALS

12. Airway Assessment
After opening airway, assess that it’s patent and clear of fluids/solids
Assess airway in unresponsive patients and responsive patients with injuries or altered mental status who may not be able to protect their own airway

13. Check Airway for Patency
Open mouth with gloved hand
Listen for sounds indicating liquid in airway
Look inside for fluids, solids, or objects
Clear using finger sweep or suction

14. Clearing a Compromised Airway With Finger Sweep
Perform finger sweep if fluids/solids seen in mouth/airway
Roll patient onto one side (left preferred)
Wipe liquids or semi-liquids from mouth
For solid objects, hook index finger, sweep object to side and out of mouth

15. Maintaining Open Airway in Unresponsive Patients
When patient is supine, airway must be kept open with either the head tilt–chin lift or the jaw thrust
An airway adjunct may be used to help maintain an open airway
If you must leave the patient’s side, move patient into recovery position to keep airway open

16. Recovery Position Helps keep airway open
Allows fluid to drain from mouth
Prevents aspiration
If possible, put victim onto left side
Continue to monitor breathing

17. Assessing Breathing

18. Assessing Breathing Look for adequate breathing in adults
Look for presence or absence of breathing in children and infants

19. Assessing Breathing
If adult not breathing adequately (breathing rate < 10 breaths per minute)
Begin rescue breaths

20. Respiratory Emergencies

21. Severe Airway Obstruction
Victim is getting no air at all
Victim will soon become unresponsive
Heart will soon stop

22. Assessment & Recognition of Airway & Ventilatory Compromise
Visual Assessment
Position
tripoid
orthopnea
Rise & Fall of chest
Paradoxical motion
Audible gasping, stridor, or wheezes
Obvious pulm edema
Skin color
Flaring of nares
Pursed lips breathing (PLB) is the act of exhaling through tightly pressed, pursed lips
Retractions
Accessory Muscle Use
Altered Mental Status
Inadequate Rate or depth of ventilations

23. Signs/Symptoms of Respiratory Distress
Gasping for air Panting
Breathing faster/slower than normal
Making wheezing or other sounds
Using accessory muscles in effort to breathe

24. Signs/Symptoms of Respiratory Distress (continued)
Inability to speak a full sentence without pausing to breathe
Skin may look pale, be cool and moist; lips/nail beds may be bluish
Dizziness or disorientation
Extreme distress
Sitting and leaning forward, hands on knees

25. Respiratory Distress in an Infant or Child
Crucial to act quickly - may rapidly progress to arrest
Infant/child may have flaring nostrils, and more obvious movements of chest muscles

26. Respiratory Distress Is a Medical Emergency
Unless condition progresses to inadequate breathing/respiratory arrest, ventilation is not needed
Patient will benefit from supplemental oxygen

27. Ventilation

28. Masks/Barrier Devices
Barrier devices recommended when giving ventilation by mouth
Pocket masks/face shields offer personal protection from patient’s fluids
With either device, keep patient’s head positioned to maintain open airway as you deliver breaths

29. Face Masks
Resuscitation mask seals over mouth/nose with port through which you blow air to give ventilations
One-way valve allows your air through mouthpiece, patient’s exhaled air exits through different opening.
When using face mask, seal mask well to face while maintaining an open airway
Use bridge of nose as guide for correct placement

30. Face Masks continued Seal mask well while maintaining open airway
How you hold mask depends on:
Your position by patient
Method to open airway
Whether you have one or two hands to seal mask

31. Position at Victim’s Side
With thumb and index finger seal top and sides of mask to victim’s head
Put thumb of second hand on lower edge of mask
Put remaining fingers of second hand under jaw to lift chin
Press mask down firmly to make seal as you lift chin

32. Position at Top of Victim’s Head: Using Head Tilt – Chin Lift
Put thumbs on both sides of mask
Put remaining fingers of both hands under angles of victim’s jaw
As you tilt head back, press mask down firmly to make seal as you lift chin

33. Position at Top of Victim’s Head: Jaw Thrust
Without tilting head back, position thumbs on mask with fingers under angles of jaw
Lift jaw as you press down with thumbs to seal mask, without tilting head back

34. Face Shield Positioned over mouth as protective barrier
Nose must be pinched closed when giving a ventilation to prevent air from coming out
Mask is generally preferred to face shield because air may leak around shield
Face Shield

35. If No Barrier Device Is Available
Give ventilations directly from your mouth to patient’s mouth, nose, or stoma
Risk of disease transmission is very low

36. Mouth to Mouth Pinch victim’s nose shut Seal your mouth over victim’s
Breathe into victim’s mouth
Watch chest rise to confirm air is going in

37. Mouth to Nose Use victim’s nose if: Mouth cannot be opened
Mouth is injured
You cannot get a good seal with mouth to mouth

38. Mouth to Nose Hold victim’s mouth closed
Seal your mouth over victim’s nose to breathe in
Open mouth to let air escape

39. Mouth to Stoma
Some people breathe through hole in lower neck – called a stoma
Cup your hand over victim’s nose and mouth
Seal your mouth over stoma or a round pediatric face mask
Give rescue breaths as usual

40. Mouth to Nose and Mouth
Infants and very small children are given rescue breaths through mouth and nose
Seal mouth over both mouth and nose
Give gentle breaths
Watch to see chest rise and fall with each breath

41. Techniques of Ventilation
With patient supine, open airway with head tilt–chin lift or the jaw thrust
Blow air while watching chest rise to make sure air is going into lungs
Don’t try to rush or blow too forcefully
Don’t take big breath to exhale more air; take a normal breath
Give each breath over about 1 second

42. Skill:
Rescue Breathing

43. Open the airway. Look, listen, and feel for adequate breathing for up to 10 seconds.

44. If not breathing adequately, give 2 breaths over 1 second each
If not breathing adequately, give 2 breaths over 1 second each. Watch chest rise and fall.

45. If first breath doesn’t go in, open the airway and try again
If first breath doesn’t go in, open the airway and try again. If it still does not go in, proceed to CPR for choking.

46. If first 2 breaths go in, check for pulse.

47. If pulse but no breathing, continue ventilations
Recheck for a pulse about every 2 minutes

48. Assessing An Airway Obstruction
Most cases in adults occur while eating
Most cases in infants and children occur while eating/playing

49. Mild Obstruction Victim is coughing forcefully
Victim is getting some air
Wheezing or high pitched sounds with breath
Do not interrupt coughing or attempts to expel object

50. Severe Obstruction Victim getting little air or none
Victim may have pale or bluish coloring around mouth and nail beds
Victim may be coughing weakly and silently or not at all
Victim cannot speak

51. Severe Foreign Body Airway Obstruction (Responsive Adult or Child)
Skill:
Severe Foreign Body Airway Obstruction (Responsive Adult or Child)

52. One leg between victim’s legs.
Stand behind victim.
One leg between victim’s legs.
Head to one side.

53. Make fist with one hand – thumb side in to victim’s abdomen

54. Grasp fist with other hand. Thrust inward and upward.

55. For pregnant victim or victim you can’t get arms around, give chest thrusts.5

56. Responsive Choking Infant Who Cannot Cry/Cough
Give alternating back slaps/chest thrusts to expel object
If Choking Infant Becomes Unresponsive
Give CPR, start with chest compressions
Check for object in mouth, remove any object you see

57. Severe Foreign Body Airway Obstruction (Responsive Infant)
Skill:
Severe Foreign Body Airway Obstruction (Responsive Infant)

58. Give up to 5 back slaps between shoulder blades

59. Roll infant face up.

60. Check for expelled object. If not present, continue with next step.

61. Give 5 chest thrusts. Check mouth for expelled object.
Repeat back slaps and chest thrusts as necessary.
Un07_10

62. Rapid Sequence Endotracheal Intubation
1.Prepair for surgical aiway.
2.Preoxigenation with 100./. O2.
3.Apply cricoid pressure at cricoid cartilage “below thyroid cartilage "or below Adam's apple.
4.Adminster a sedative drug “Midazolam 2-3 mg i.v”.
5.Adminster “1-2 mg/kg succinylcholine i.v .
6.Intubate the patient with orotracheal tube.
7.Inflate the cuff and confirm tube placement by..
auscultation the chest or by capneogragh ”presence of CO2 in exhaled air”
8.Release cricoid pressure.
9.Ventilate the patient.

63. Indications of Endotracheal Intubation
1. when pt can not protect their airway ( coma, resp. and cardiac arrest).
2. In patient with upper airway compromise
3. In unresponsie patient who lack a gag reflex
4. when there is airway obstruction caused by foreign body, trauma, anaphylaxis
5. when prolonged artificial respiration is needed
6. effective root for administration of medications (epinephrine, atropine, lidocaine, vasopressin)

64. Laryngeal Mask Airway (LMA)

65. Stylet
Plastic-coated wire may be inserted in the ET tube to add rigidity and shape to the tube.
Bend the tip of the stylet to form a gentle curve in adults.
Bend the tip of the stylet to form a hockey stick shape for an infant and child.
Confirm that the stylet is not sticking out past the end of the ET tube.

66. Intubation Complications
Intubating the right main stem bronchus
Intubating the esophagus
Aggravating spinal injuries
Taking too long to ventilate
Patient vomiting
Soft-tissue trauma
Mechanical failure
Patient intolerant of the ET tube
Decrease in heart rate

67. Laryngoscope Sweeps the tongue out of the way and aligns the airway
Has a light powered by batteries in handle
Has blades that connect to handle
Blades are curved or straight.
They range in size from 0 to 4.

68. Curved Blade

69. Straight Blade

70. Cricothyroidectomy absolute need for a definitive airway
unable to perform ETT due for structural or anatomic reasons,
unable to clear an upper airway obstruction
multiple unsuccessful attempts at ETT

71. Surgical Cricothyrotomy
Can't intubate
Can't ventilate
Severe facial or nasal injuries (that do not allow oral or nasal tracheal intubation)
Massive midfacial trauma
Possible cervical spine trauma preventing adequate ventilation
Anaphylaxis
Chemical inhalation injuries
foreign body, angioedema

74. Contraindications (relative)
Age < 10 years
evidence of tracheal transection

75. سوپاس بۆ ئەو کاتەی پێتان بەخشین
پرسیارکردن مافی خۆتە ؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟ Dr. Sarwar Arif Star E Mail: Mobile no.: face book: Sarwar Arif